2026 Southeastern Residency Conference

Background
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve glycemic control and provide cardiovascular and renal benefits in patients with type 2 diabetes mellitus (T2DM), heart failure (HF), and chronic kidney disease (CKD). Despite strong outpatient guideline support, data on inpatient use remains limited. Insulin remains the standard of care for inpatient glycemic management due to safety concerns, including euglycemic diabetic ketoacidosis and acute kidney injury. Consequently, inpatient SGLT2i use remains controversial due to conflicting guideline recommendations and limited safety data, particularly in hospitalized patients with CKD and HF.
Methodology
This IRB-approved multicenter retrospective study included hospitalized adult patients (≥18 years) with T2DM, HF, and CKD admitted between August 2023 and November 2025 who received either SGLT2i in combination with scheduled multimodal insulin (intervention group) or scheduled multimodal insulin alone (control group) Exclusion criteria included type 1 diabetes mellitus, pregnancy or lactation, intensive care unit admission, or use of continuous insulin infusion. The primary outcome was glycemic control measured by daily blood glucose levels. Secondary outcomes included percentage of blood glucose readings in target range (100 to 180 mg/dL), inpatient mortality, length of hospital stay (days), number of insulin injections administered per day, incidence of diabetic ketoacidosis (defined as bicarbonate < 18 mmol/L, pH< 7.3, AG > 12, and serum ketone or urine ketone), incidence of hypoglycemic events (defined as blood glucose < 70 mg/dL), incidence of acute kidney injury (defined as an increase in serum creatinine > 0.3 mg/dL or ≥ 1.5 times above baseline), mean change in body weight.
Descriptive statistics summarize baseline characteristics. Normality was assessed using the Shapiro-Wilk test. Categorical variables were analyzed using Chi-Square tests. Continuous variables were analyzed using Student’s t-test or Mann-Whitney U tests, as appropriate. Statistical significance was defined as a two-tailed alpha of 0.05.
Results
A total of 200 patients were included (100 per group). Baseline characteristics were generally similar between groups except the insulin-alone group had lower eGFR at admission compared to the SGLT2i plus insulin group (20.5 vs. 41.1 mL/min/1.73 m2) and higher serum creatinine at admission (2.77 vs. 1.52 mg/dL). Median daily blood glucose levels were numerically higher in the SGLT2i plus multimodal insulin group compared to multimodal insulin therapy alone (165 vs 160 mg/dL; P < 0.001) Comparable percentage of blood glucose readings within target range (57% vs 59% P = 0.645) were observed.
With secondary efficacy outcomes, there were no significant differences in length of stay (6 vs 5 days; P = 0.199), total daily insulin dose (12.5 vs 8.5 units; P = 0.165), or weight change (-0.05 vs 0.28 P = 0.073). Secondary safety outcomes, including inpatient mortality (1 vs 3; P = 0.621), hypoglycemic events (11 vs 18; P = 0.16), and diabetic ketoacidosis (1 vs 0; P = 1.0), were also comparable between groups
The SGLT2i group had significantly lower 90-day all-cause readmission rates (51% vs 72%; P = 0.002) and lower incidence of acute kidney injury (33% vs 49.5%; P = 0.018), but a higher number of insulin injections per day (3 vs 2; P = 0.01).
Conclusions
Albeit being statistically significant, the addition of SGLT2 inhibitors to insulin therapy did not result in clinically meaningful improvements in glycemic control compared with insulin alone. Observed SGLT2 inhibitor use may be associated with significantly lower rates of acute kidney injury and 90-day readmissions, suggesting potential benefits beyond glycemic management. These findings support further investigation into the role of SGLT2 inhibitors in the inpatient setting.